When the lingual artery is severed by an overdrilling bur, it shrinks toward the external carotid artery.  Hemostasis is difficult to achieve without emergency surgery.  Failure to recognize the proximity of the lingual concavity may lead to perforation of the lingual plate while osteotomy is forming (Fig.6 red arrow) and potentially damage the lingual artery in the submandibular fossa.

Although CBCT is essential for recognition of this special anatomy, a surgical technique is the most critical step to avoid the injury.  That is to use two fingers (Fig.7 blue circles) to hold the buccal and lingual plates as low as possible and let the tactile sense guide you and keep the osteotomy in the middle of the ridge (pink arrow).  One of the fingers may sense the vibration before perforation of the buccal or lingual plate.  Use a long explorer to probe the osteotomy site for wall integrity after each bur.  A surgical stent is also helpful.  If an immediate implant is placed, the osteotomy should be initiated in the buccal wall of the socket of the 2nd molar.

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Xin Wei, DDS, PhD, MS 1st edition 04/14/2013, last revision 04/14/2014